Healthcare Provider Details

I. General information

NPI: 1255836193
Provider Name (Legal Business Name): MATTHEW KOBE KING LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 EMMA RD
BASALT CO
81621-9169
US

IV. Provider business mailing address

2700 GILSTRAP CT STE 230
GLENWOOD SPRINGS CO
81601-8735
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-2840
  • Fax: 970-945-2893
Mailing address:
  • Phone: 970-945-2840
  • Fax: 970-945-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0001559
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0008319
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: